ABSTRACT
ABSTRACT Purpose: Evaluation of lid contour and marginal peak point changes to compare outcomes of external levator advancement and Müller's muscle conjunctival resection surgery in unilateral ptosis. Methods: We reviewed the charts of unilateral ptosis patients who underwent external levator advancement or Müller's muscle conjunctival resection. Eyelid contour analysis was conducted on preoperative and 6-month postoperative digital images. This was performed with the multiple margin reflex distances technique, measuring the vertical distance from a line intersecting the center of the pupil to the eyelid margin at 10 positions at 2 mm intervals. The marginal peak point changes were analyzed digitally using the coordinates of the peak point according to the pupil center. Each position's mean distance was compared preoperatively, postoperatively, and with the fellow eyelid. Results: Sixteen patients underwent external levator advancement and 16 patients had Müller's muscle conjunctival resection. The mean margin reflex distance was improved by both techniques (1.46 vs. 2.43 mm and 1.12 vs. 2.25 mm, p=0.008 and p=0.0001 respectively) and approached that of the fellow eyelid (2.43 vs. 2.88 and 2.25 vs. 2.58 mm, p=0.23 and p=0.19, respectively). However, statistically significant lid margin elevation was limited to between the N6 and T6 points in the external levator advancement group. Whereas, significant elevation was achieved along the whole lid margin in the Müller's muscle conjunctival resection group. The marginal peak point was shifted slightly laterally in the external levator advancement group (p=0.11). Conclusions: Both techniques provide effective lid elevation, however, the external levator advancement's effect lessens toward the canthi while Müller's muscle conjunctival resection provides more uniform elevation across the lid margin. The margin reflex distance alone is not sufficient to reflect contour changes.
ABSTRACT
Tear function and ocular surface after muller muscle- conjunctival resection Suat Hayri Uğurbaş, Atilla Alpay, Burak Bahadır,1 and Sılay Cantürk UğurbaşDepartment of Ophthalmology, Bülent Ecevit University, Zonguldak, Turkey1Department of Pathology, Bülent Ecevit University, Zonguldak, TurkeyCorrespondence to: Dr. Atilla Alpay, Bülent Ecevit Universitesi Tıp Fakültesi Göz Hastalıkları Anabilim Dalı Kozlu Zonguldak 67600, E-mail: moc.liamtoh@yaplaallita Author information ► Article notes ► Copyright and License information ► Received 2010 Nov 2; Accepted 2012 Apr 11. Copyright : © Indian Journal of OphthalmologyThis is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Go to:Abstract.Muller muscle-conjunctival resection (MCR) is a surgical technique to correct mild and moderate ptosis. In this study, tear function tests and ocular surface are evaluated in patients who underwent unilateral surgery. Sixteen patients with normal preoperative tear function who underwent unilateral MCR were evaluated prospectively. The fellow eyes of the patients were taken as the control group. A dry eye assessment questionnaire, Schirmer testing, tear film break-up time, fluorescein stain, Rose-Bengal stain, and conjunctival impression cytology were used to assess the tear film functions and ocular surface changes in the operated and non-operated eyes. There was no statistically significant difference in the tear function tests and goblet cell densities between the operated and non-operated eyes. The results indicate that an MCR procedure has no apparent effect on tear function tests and goblet cell density in patients with normal preoperative tear function. Keywords: Blepharoptosis surgery, conjunctiva, tear Muller's muscle-conjunctival resection (MCR) is a form of posterior approach surgery for ptosis correction. Although this technique has been reported to give excellent results, there is a question of its effect on tear film components. There are several studies concluding no significant effect of MCR on tear production.[1] These studies are based on Schirmer testing (ST) and questioning of dry eye symptoms only. In this study, we studied all of dry eye tests including a dry eye questionnaire, ST, tear film break-up time (TBUT), vital staining, meibomian gland evaluation and conjunctival impression cytology. Go to:Materials and Methods.Thirty-two eyes of 16 patients who underwent unilateral ptosis surgery were enrolled in the study. The fellow eyes of the patients were taken as the control group. A complete ophthalmologic examination of patients was performed including preoperative Schirmer and TBUT tests. The patients with other ocular disease, dry eye, history of a systemic disease that would affect ocular surface, history of contact lens use, and prior conjunctival surgery were excluded from the study. All patients underwent ptosis repair by an MCR with a technique similar to the described by Putterman.[1] A subjective dry eye questionnaire was given to the patients questioning various dry eye symptoms, frequency of dryness, grittiness, burning, redness, crust formation on lashes and stickiness of eyelids in the morning.[2] Responses were graded as follows: 0 - never; 1 - rare; 2 - sometimes; 3 - frequently; or 4 - always. The total score was calculated with the sum of symptom grades in each eye. Schirmer and TBUT tests were performed after an application of a drop of proparacaine hydrochloride 0.5%. The procedure was repeated 3 times, and the average of measurements was recorded. Fluorescein staining was recorded for 5 regions of the cornea (superior, inferior, nasal, temporal, central) and 4 regions of the conjunctiva (superior, inferior, nasal, temporal). Each region was graded from 0 to 4. The total staining score was the sum of the scores of all regions. Rose-Bengal staining (RBS) of the conjunctiva was performed by using a Contacare Rose-Bengal ophthalmic Strip (Contacare, Baroda, India); initially wetted with non-preserved buffered saline and then instilled on the inferior bulbar conjunctiva. An evaluation of RBS was similar to fluorescein staining. The eyelid margin was checked for meibomian gland disease (MGD) with slit lamp examination. Grade-0 indicated that all glands were unblocked. Grade-1 indicated 1 to 2 blocked glands. Grade-2 indicated 3 to 4 blocked glands with thick secretions but without expression of glands. Grade-3 indicated that half of the glands were blocked. Grade-4 indicated more than half of the glands were blocked with viscous secretions. Grade-1 or higher was considered as MGD positive.[3] Impression cytology specimens were collected from the temporal and nasal conjunctiva of each eye using Nitrocellulose (Sartorius, Göttingen, Germany) filter paper. Specimens were stained with periodic acid-Schiff stain. The quantitative studies of conjunctival goblet cells and squamous metaplasia of conjunctival epithelial cells were conducted by taking photographs with a calibrated grid under a light microscope. Five non-overlapping areas of each randomly-selected sample were photographed and averaged for a single score. The Goblet cell densities were reported as cells per square millimeter with standard deviations. The specimens were also assigned a grade of conjunctival epithelial squamous metaplasia according to Nelson's grading scheme.[4] The results were analyzed by using paired t-test and Wilcoxon matched pair test. P < 0.05 was considered statistically significant. Go to:Results.The patients consisted of 11 women and 5 men. The mean age was 51.4 ± 19.5 (range 14 - 76) years. Patients were followed-up for mean 18.5 ± 10.2 (4 - 40) months. The mean subjective dry eye questionnaire score was 2.68 ± 3.98 points in operated eyes and 2.00 ± 2.63 points in control eyes. There was no significant difference between 2 groups (P = 0.54). There was no difference in the ST and TBUT scores before and after surgery in both operated and in the control eyes (P = 0.79, P = 1.00, respectively). The mean fluorescein and RBS scores, meibomian gland disease score and squamous metaplasia grading score of operated and non-operated eyes of each patient also showed no significant differences [Table 1]. Table 1Tear function and ocular surface examinationsAn impression cytology analysis showed no statistically significant change in goblet cell densities between operated and the control eyes (> 0.05).